2. Bilateral Cleft Anatomy 19

Home , Lip, Mucocutaneous junction, Premaxilla

BILATERAL CLEFT ANATOMY

IS ATTACHED TO THE SINGLE CLEFT THE PREMAXILLA NORMALLY ROTATED OUTWARD MAXILLA ON ONE SIDE AND THIS ENTIRE COMPONENT IS

THE CLEFT SIDE MAXILLA IN AN VARYING DEGREES FROM ASYMMETRICAL DIFFERENT DISTORTION DOUBLE CLEFTS PRESENT AN ENTIRELY CONFIGURA

TION IN THE COMPLETE BILATERAL CLEFT THE PREMAXILLA IS UNATTACHED THREE WHICH TO EITHER MAXILLA THUS THERE ARE SEPARATE COMPONENTS

IN THEIR DISTORTION THE MAXILLAE ARE MORE OR LESS SYMMETRICAL TWO WHILE THE ARE USUALLY EQUAL TO EACH OTHER IN SIZE AND POSITION

FORWARD ITS IN CENTRAL PREMAXILLARY ELEMENT PROCEEDS ON OWN

WITHIN ITSELF FOR DIFFERENT DEGREES BUT WITH SYMMETRY EXCEPT IJI

POSSIBLE DEVIATION FRONTONASAL THE COMPLETE SEPARATION OF THE CENTRAL COMPONENT

OF PROLABIUM AND PREMAXILLA FROM THE LATERAL MAXILLARY SEGMENTS THE VASCULAR ABNORMALLY INFLUENCES NOSE PHILTRUM MUSCULATURE AND OF ALL THREE ELEMENTS ITY NERVE SUPPLY GROWTH DEVELOPMENT

WHERE THE CLEFT IS INCOMPLETE ON BOTH SIDES THE DEFORMITY IS

LESS AND IS STILL SYMMETRICAL IN SUCH CASE THERE IS USUALLY MORE

OR LESS INTACT ALVEOLUS AND LITTLE OR NO PROTRUSION OF THE PRE THE MAXILLA THE COLUMELLA IS LIKELY TO BE LONGER THAN IN COMPLETE

CLEFT BUT NOT OF NORMAL LENGTH SOMETIMES SOMETIMES THE DEGREE OF CLEFT VARIES ON EACH SIDE

SIDE THE INCOMPLETENESS SHOWS AS ONLY THE SLIGHTEST NOTCH ON ONE SIDE OR THERE CLEFT ON THE OPPOSITE AND HALFWAY OR THREEQUARTER ON THE CLEFT ONE SIDE AND AN INCOMPLETE ONE CAN BE COMPLETE ON OF THE EXASPERATING ASPECT OTHER WHICH CONDITION EXAGGERATES THE ROTATION OF THE IN THE AND NOSE BUT IN ASYMMETRY NOT ONLY LIP ONE SIDE HELPS THE EXISTENCE OF SOME ATTACHMENT ON PREMAXILLA OF THE THE UNINHIBITED CENTRAL PROJECTION OF COURSE TO CHECK

PREMAXILLA WORKING DURING THE EVEN THE MOST MINOR UNILATERAL SYNECHIA CURB OF THE EXPLOSIVE PERIOD CAN SOME PRENATAL AND POSTNATAL REDUCING ITS PROTRUSION THRUST OF THE PREMAXILLA APPRECIABLY 11 IN THE 30S HERE IS CASE VEAU SKETCHED AND COMMENTED ON THIS SIMONARTS BAND THAT DEMONSTRATES MODEST RESTRAINT BY TINY

SIMONARTS BAND

ENGLAND IN 1948 WHILE AT ROOKSDOWN HOUSE BASINGSROKE

RESIDUAL SKIN BRIDGES SPAN 1949 LEARNED TO REFER TO CONGENITAL SIMONARTS BANDS HOLDS OF LIP CLEFTS AS NING THE UPPER PORTION SITNONARTZ BANDS IN RECENT YEARS WORTH LATER REFERRED TO THEM AS DISCOVER THE ORIGIN OF THIS MYS SEARCH HAS BEEN UNDERWAY TO II THESE IN 1976 TOM GIBSON INTRIGUED BY TERIOUS SOBRIQUET HAD GUSTAV SIMON IN HIS 1868 BOOK PRESENTED TERMS FOUND THAT AND FOR BILATERAL CLEFTS CHAPTER 13 II AN ADHESIONTYPE OPERATION MUST HAVE WRITTEN ABOUT DEDUCED THAT SOMEONE SUBSEQUENTLY THE TRANSVERSE BANDS OF THE BY CREATING OLO REPOSITIONING PREMAXILLA THIS WOULD BE AN BAND OF ARZT IN ROSTOCK OPERATIVE WOLFE MEANWHILE TURNED TO ANTHONY NOT CONGENITAL ONE FORWARDED TWO LEAD REFER AND HE TURNED TO SAM PRUZANSKY WHO

LES SPONTANSJOURFLA ENCES SIMONART SUR AMPUTATIONS

20 ALSO ARCHIVES MLICALES JUNE 1846 PP 327330 DES CONNAISSANCES WITH THESE REFERENCES TONY 1846 112119 A4EDICALES BELGES BOOKS LIBRARIAN FRANCIS RICHARD WOLFE RARE WOLFE WROTE MEDICAL SCHOOL WHO OF MEDICINE HARVARD COUNTWAY LIBRARY ARTICLE THEN TONY WOLFE OF THE FIRST SIMONART SENT PHOTOCOPIES FOR INFORMATION ON MICHAEL MEESEN LIEGE WROTE HIS FRIEND NOTICE OBTAINED FROM BELGIAN REGISTRY SIMONART AND RECEIVED CILIEN THERE WAS MAN NAMED PIERREJOSEPH WHICH INDICATED IN THE OF BRUSSELS BORN AGREG6 AT UNIVERSITY SIMONART PROFESSOR 30 DIED WAVRE DECEMBER 19 1846 AGE WAVRE MAY 20 1816 OF DISCUSSING CASES SPONTANEOUS SIMONART HAD BEEN PREVIOUSLY OF THE EXTREMITIES DUE TO EN AND DEEP GROOVING AMPUTATIONS AMNIOTIC BANDS AFTER EITHER UMBILICAL CORD OR BY CIRCLEIRIENT BY AN THE LITERATURE HE MENTIONED THE CASES IN REVIEWING PREVIOUS IN BRUSSELS HERE OF LATERAL FACIAL CLEFT CASE SEEN INTERESTING TYPE LES SPON FROM HIS NOTES SUR AMPUTATIONS ARE EXCERPTS PAPER ET DE DES CONNAISSANCES M6DI CAES PRATIQUES TANS IN JOURNAL IN THE ORIGINAL JUNE 1846 PP 328329 PRESENTED

FRENCH AND TRANSLATED INTO ENGLISH

DE LA MARERNIT DE BRUXELLES CHEZ UN FETUS RECUEJILI II PEU TEMPS COMME DE IA COMMISSUTE LABIALE EST LA JONE DE CHAQUE C6T PARTIR REMONRE UNE BRIDE DE CETTE ESP QUI COUP DANS ROUTE SON 6PAISSEUR PAR

VERS 1OCCIPUT THE CHEEK ON THE MATERNITE OF BRUSSELS IN FETUS OBTAINED NOT LONG AGO AT THICKNESS WAS CUT IN ALL ITS BY EACH SIDE FROM THE LABIAL COMMISSUTE EXTENDED TO THE OCCIPUT BAND OF THIS TYPE WHICH UP

AMNIOTIC BANDS HE WHETHER THE LATER IN HIS ARTICLE QUERIED HE ALSO STATED INTRAUTERINE INFLAMMATORY PROCESSES REPRESENTED

LA ET QUASI COUPS QUE MOLLES SOUSCUTANS SONT D6JA SEPAREES LES PATTIES AMINCISSEMENT INTACTE CELLECI NA SUBI QUUN LEGER PEAU RESTE ENCORE AND ALMOST DIVIDED THE SUBCUTANEOUS SOFT TISSUES ARE ALREADY SEPARATED THINNING IT HAS ONLY SLIGHT WITH THE SKIN REMAINING INTACT UNDERGONE

DID INDEED REFER TO CONGENITAL THUS IT SEEMS THAT AS SIMONART AND CHEEK FROM THE LABIAL COMMISSURE SKIN BRIDGES IN THE AREA BANDS SOME THE THE NAME SIMONARTS TO THE OCCIPUT OVER YEARS THE RESIDUAL SKIN BRIDGES CROSSING HOW BECAME ASSOCIATED WITH

OF CLEFTS UPPER PORTION LIP

21 AN ANATOMISTS DETAIL

OF THE BILATERAL IN 1954 SUMMERFIELD KING DESCRIBED THE ANATOMY WITH THE NOSTRILS WHICH DEFORMITY AS TWO DEEP CLEFTS CONTINUOUS MEDIAN RUBERCLE FROM THE LATERAL ELEMENTS OF THE SEPARATE PAIRED THE HAS TWO BULGES CONTAINING THE UPPER LIP PREMAXILLA LARGE MEDIAN INCISOR TEETH AND THE BONE RELATED TO THEM NARROW

THE TO THE IS RIDGE THE FRENULUM ATTACHING PREMAXILLA PROLABIUM

FORMED OF CONNECTIVE TISSUE COVERED BY THICK UNCORNIFIED CONTINUES INTO STRATIFIED EPITHELIUM THE INFERIOR FRENULUM OF THE WITH FIBROUS BROAD VSHAPED RED LIP MARGIN PROLABIUM ITS HAS CONNECTIVC TISSUE VERY RICHLY VASCULARIZED EPITHELIUM THE RED THIN STRATUM CORNEUM WITHOUT GLANDS OR HAIRS BETWEEN

THE THERE ON EITHER SIDE NARROW STRIP LIP MARGIN AND GUM LIES OF MUCOUS MEMBRANE WITH AN UNCORNIFIED TYPE OF STRATIFIED

OF MODERATE THICKNESS AS EVERTED POSTERIOR EPITHELIUM REPRESENTED OF THE SULCUS BETWEEN SURFACE OF LIP THE EPITHELIUM PROLABIUM

THINNER TO THE RED IN THE AND GUM IS SIMILAR BUT SUPERIOR MARGIN COVERED WITH SKIN PROLABIUM IS TRIANGULAR OR CIRCULAR AREA HAIRY THE NEAR THE RED LIP MARGIN MUCOCUTANEOUSJUNCTION ALTHOUGH

STILL OF SKIN HAIRS ARE OR EPIRHELIUM IS CLEARLY ORDINARY TYPE SCANTY ABSENT

THE MEDIAN RUBERCLE CONTAINS THE RIGHT AND LEFT PREMAXILLAE

UNITED BY MEDIAN SUTURE EACH PREMAXILLA IS ENLARGED LATERALLY

CENTRAL INCISOR INFEROLATERALLY TO CARRY TWO INCISOR TEETH LOOKING

AND LATERAL INCISOR AT HIGHER LEVEL LOOKING POSREROLATERALLY TOOTH THEIR SOCKETS ARE SHALLOW GREAT PART OF THE ROOTS BEING

COVERED ONLY WITH SOFT TISSUE EXTENSION FROM THE IS EXTENDING POSTERIORLY AS AN PREMAXILLAE

WHICH IN THIS RESTS THE SUBVOMERINE PROCESS PRODUCES GROOVE THE NARROW VOMER THE CARTILAGINOUS NASAL SEPTUM AND LONG SHALLOW ALVEOLAR THE MAXILLA IS REPRESENTED ON EACH SIDE BY

MILK TEETH AND FRONTAL AND PROCESS CONTAINING SOME BY PROCESS BUT THERE IS NO MAXILLO PAIR OF MINUTE PALARAL PROCESSES

FOR THE BONES ARE PREMAXILLARY INCISIVE SUTURE WIDELY SEPARATED

22 LIP ANATOMY

PROLABIUM

SOFT TISSUE END OF THE FRONTONASAL THE PROLABIUM IS THE POINT IN SIZE FROM FEW MILLIMETERS TO OVER COMPONENT IT MAY VARY AND WIDTH IN BILATERAL CLEFT IT HAS BEEN CENTIMETER IN HEIGHT NO CUPIDS BOWNO PHILTRUM TRAGICALLY SHORTCHANGED POSSESSING COLUMNS AND NO LABIAL SULCUS AND IS ATTACHED DIMPLE NO PHILTRUM

AND IS ALL THIS LITTLE OF TO LITTLE OR NO COLUMELLA THAT NOT PATCH

THE FLAT SKIN AND MUCOSA IS LACKING SOFT PROLABIUM SITTING

IS FORLORNLY ON THE FRONT OF THE UNRESTRAINED AGGRESSIVE PREMAXILLA

EVIDENCE THAT MUSCLE MIGRATION FROM THE MAXILLARY PROCESSES

NOT REINFORCED THIS MINIMAL BIT OF THE FRONTONASAL PROCESS

MUSCLE DISCREPANCY

AS NOTED INTERMITTENTLY BY MULLEN VEAU LEE BURIAN DAVIS STANEK KING STARK EHRMANN REES SWINYARD CONVERSE FARA SMAHEL LATHAM DUFFY AND OTHERS THERE SIMPLY ARE NO MUSCLE

FIBERS IN THE PROLABIUM OF COMPLETE BILATERAL CLEFTS ALTHOUGH THEY OF MUSCLE ARE PLENTIFUL IN THE CHEEK AND OVER THE SIDE THE NOSE

FIBERS ARE HOWEVER FOUND IN THE PROLABIUM OF INCOMPLETE BILAT

ERAL CLEFTS AND THE AMOUNT VARIES INVERSELY WITH THE DEGREE OF THE

CLEFTINGTHE LESS SEVERE THE CLEFT THE MORE MUSCLE IN THE

PROLABIUM THESE FINDINGS SEEM COMPATIBLE WITH THE MESODERM

MIGRATION AND MERGING THEORIES

IN 1931 MULLEN EXPRESSED SUSPICION THAT THERE WAS NOT ANY

MUSCLE AND IN 1946 LEE DOCUMENTED THE ABSENCE OF MUSCLE IN

THE PROLABIUM IN 1958 STARK AND EHRMANN RECOGNIZED THAT THE

PROLABIUM CONTAINED NORMAL MESODERM BUT WITHOUT MUSCLE

IT IS INTERESTING HOW MOD THOMAS REES SON OF MORMON

IN PROFESSOR OF BIOLOGY AT THE UNIVERSITY OF UTAH GOT INTERESTED

THE MUSCLE OF THE PROLABIUM ABOUT 1955 WHILE TRAINING WITH

MCLNDOE AT EAST GRINSTEAD REES OPERATED ON 15YEAROLD IRISH

BOY WITH COMPLETE BILATERAL CLEFT THE PROLABIUM WAS SO ATTEN

UATED THAT HE USED IT FOR COLUMELLA NOTING ITS ABSENCE OF MUSCLE THE FOLLOWING YEAR MCLNDOE TOOK REES WITH HIM TO HIS GREAT

WHEAT FARM ON THE NORTHERN SLOPE OF KILIMANJARO EAST AFRICA

AND AND MICHAEL STARTED DURING THIS TRIP MCLNDOE REES WOOD

THOMAS REES 23 PLAN THAT WAS LATER TO DEVELOP INTO THE FLYING DOCTORS OF EAST

AFRICA DURING OTHER TRIPS TO AFRICA REES OPERATED ON TWO OTHER

ADULT BILATERAL CLEFTS WITH ATTENUATED PROLABIUMS AS HE WROTE

RECENTLY

THESE THREE CASES LATER STIMULATED ME TO LOOK INTO THE PROHIEM OF MUSCLE IN

THE PROLABIUM

IN 1962 WITH SWINYARD AND CONVERSE HE REPORTED ELECTRO

MYOGRAPHIC EVIDENCE OF ABSENCE OF MUSCLE ACTIVITY IN THE

PROLABIUM

HISTOLOGICAL PICTURE

IN 1967 FARA AND SMAHEL MADE SOME DEDUCTIONS FROM THE STUDY

OF 330 CASES OF COMPLETE BILATERAL CLEFT LIPS OPERATED ON IN RECENT OF THE YEARS ONLY PERCENT OF THE BILATERAL CASES WERE CLEFTS JUST

LIP AND ALVEOLUS AND NONE WERE CLEFTS OF THE LIP ALONE THEIR

MICROSCOPIC SECTIONS OF THE PROLABIUM OF STILLBORNS AND CHILDTEN

FIVE OF REVEALED IN VEAUS TO SEVEN MONTHS AGE CONCURRENCE

ORIGINAL ASSERTION THAT THE PROLABIUM SUFFERS FROM MUSCULAR

STERILITY THEY NOTED

NO STRIATED MUSCLE FIBERS WHETHER DIFFERENTIATED OR IN VARIOUS STAGES OF

DIFFERENTIATION

ORBICULARIS ORIS MUSCLE FIBER DIRECTION

OF IN 1960 WAYNE SLAUGHTER HENRY AND BERGER

LOYOLA UNIVERSITY CHICAGO NOTED THAT THE MUSCULAR COMPONENTS

IN CLEFTS DO ONE OF SEVERAL THINGS

EITHER THEY TERMINATE IN RATHER INDISCRETE FASHION LEAVING SARCOLEMMA

WITH VAGUE UNCLEAR COMPONENTS PRESENT OR THEY FADE INTO CONNECTIVE

TISSUE OR THE MUSCLE FASCICLES PREDOMINANTLY TURN TOWARD THE NOSTRIL

WAYNE SLAUGHTER IN 1966 PENNISI SHADISH AND KLABUNDE NOTED THIS SAME

ORBICULARIS OTIS MUSCLE DISORIENTATION WITH ITS PERIPHERAL FIBERS

CLEFT RUNNING PARALLEL TO THE EDGES OF THE

AS EARLY AS 1965 FARA AND HRIVNAKOVA MENTIONED THAT THE

ORBICULARIS OTIS MUSCLE FIBERS PARALLEL THE CLEFT EDGES IN INCOMPLETE

24 WITH REEMPHASIZING THE LACK OF STRIATED CLEFTS BY 1967 ALONG FARA AND SMAHEL NOTED IMMATURE FINE MUSCLE IN THE PROLABIUM CONNECTIVE FELTLIKE TISSUE AND RICH VASCULAR NET COLLAGENOUS FOUND WORK IN THE LATERAL LIP SEGMENTS THEY

THE OF THE THE MUSCLE BUNDLES RUN ALONG EDGE CLEFT TURNING UPWARDS

WHERE ALL IN THE TOWATDS THE LINE OF THE NASAL WING THEY NEATLY DISAPPEAR

DO THE MUSCLE FIBERS SHOW TO SUBMUCOSAL LAYER ONLY RARELY TENDENCY

ADVANCE IN HORIZONTAL DIRECTION

MIROSLAV FARA

FURTHER EVIDENCE WAS PRESENTED IN 1968 BY FARA WHOREPORTED

THE DISSECTION OF ONE BILATERAL INCOMPLETE AND SIX BILATERAL COM

CLEFTS OF THE HE NOTED THE SAME DIRECTION OF THE PLETE LIP UPWARD IN THE LATERAL MUSCLE FIBERS RUNNING PARALLEL TO THE CLEFT EDGES LIP AND THE SAME VASCULAR NETWORKS THE SEGMENTS COURSING ALONG EDGE

AS FOUND IN UNILATERAL CLEFTS THE PROLABIUM OF COMPLETE CLEFTS

RICH VASCULAR HAD NO MUSCLE AND ALTHOUGH POSSESSING NETWORK IN BILATERAL ONLY COLLAGENOUS CONNECTIVE TISSUE ONE INCOMPLETE

CLEFT THE MUSCLE OF THE LATERAL SEGMENT CROSSED THE BRIDGE OF THE MEDIAL CLEFT QUITE SMOOTHLY INTO THE LIP PROLABIUM COMPLETELY

FILLING IT FARA FORTIFIED WITH 28 EXCISED BRIDGES FROM BILATERAL

FIBERS INCOMPLETE CLEFTS REPORTED THEM WELL FILLED WITH MUSCLE

FROM THE LATERAL INTO THE MEDIAL PENETRATING SEGMENTS PROLABIUM

AND SPREADING OPEN LIKE FAN HE CONJECTURED THAT THE PRO WITHOUT LABIUM PARTIALLY ISOLATED BY THE CLEFTS AND ORIGINALLY ANY

MUSCLE FIBERS DIRECTLY ABSORBED THE NECESSARY TISSUE FROM THE

LATERAL RICHLY MUSCLED ELEMENTS

ROSS AND JOHNSTON IN THEIR 1972 BOOK CLEFT LIP

AND PALATE SIMPLIFY THE MUSCLE ANATOMY IN BILATERAL CLEFTS

INFLUENCE THE INTO THE CLEFT OF THE LIP HAS CONSIDERABLE ON MYOBLASTS MOVING

IN THE THOSE WHICH THE LIP FROM THE HYOID ARCH MUSCLE PLATES LIP MYOBLASTS

WILL FORM THE ORBICULARIS OTIS ENCOUNTER THE CLEFT MARGIN AND TURN UPWARD IT TOWARD THE BASE OF THE NOSE EITHER AT THE ALAR WINGS OR IN THE ANTERIOR NASAL

SPINE REGION WHERE THEY EVENTUALLY FORM THEIR ATTACHMENTS THIS PHENOME

DIFFERENTIATE INTO MUSCLE CELLS NON SUGGESTS THAT MYOBLASTS WILL NOR MATURE

UNLESS THEY FIND SKELETAL OR CONNECTIVE TISSUE STRUCTURE TO WHICH THEY CAN

ATTACH

25 A4USCLE IN BILATERAL ANATOMY CLEFTS

THE FIBERS OF THE ORBICULARIS OTIS MUSCLE IN EACH LATERAL LIP ELEMENT

SWEEP UP ALONG THE CLEFT EDGE TOWATD THE ALAT BASE THE LACK OF

TNUSCLC CONTINUITY ACROSS THE LIP PLACES THE LATERAL ELEMENTS AT THE OF THE MERCY ACCESSORY MUSCLES THROUGH THE MODIOLUS

IN INCOMPLETE BILATERAL CLEFTS THE ORBICULARIS OTIS MUSCLE FIBERS

RUN THE LATERAL PARALLEL TO LIP EDGES BUT MANAGE TO SNEAK SOME

FIBERS THROUGH THE SKIN BRIDGES WHICH THEN FAN OUT INTO THE

PROLABIUM WITH SMILING AND CRYING THE LATETAL LIP ELEMENTS ARE

PARTIALLY RESTRAINED BY THE BRIDGES AND THE PROLABIUM FLATTENS AND

STRETCHES FROM SIDE TO SIDE AT LEAST TO SOME EXTENT

IN THIS BILATERAL INCOMPLETE CLEFT LIP THE BRIDGES ARE SO ATRENU

ATED THAT VERY LITTLE MUSCLE HAS BEEN ABLE TO MIGRATE ACROSS THE

CLEFTS YAWNING THEREFORE LEAVES THE PROLABIUM ALMOST TOTALLY

UNPERTURBED

IN COMPLETE BILATERAL CLEFTS THE ORBICULARIS OTIS MUSCLE FIBERS IN

THE LATERAL LIP ELEMENTS RUN PARALLEL TO THE CLEFT EDGES TOWARD THE

ALAR BASES THE PROLABIUM ITSELF HAS ABSOLUTELY NO MUSCLE DURING

EXPRESSION OF EMOTION BY LAUGHING AND CRYING WHILE THE LATERAL

LIP ELEMENTS ARE JERKED WITHOUT RESTRAINT UPWARD AND BACKWARD BY

THE UNOPPOSED ACCESSORY MUSCLES THE PROLABIUM SIRS SOLEMNLY ON

THE PREMAXILLA WHOLLY UNAFFECTED

SENSORY NERVES

IN BILATERAL CLEFTS THE LONG SPHENOPALATINE NERVE PASSES DOWN ON

EACH SIDE OF THE VOMER SUPPLYING ITS MUCOUSMEMBRANE AND THAT

OF THE THE ANTERIOR ERHMOIDAL PREMAXILLA NERVE PASSES VERTICALLY

26 INCOMPLETE CLEFT ATTACHED TO SKL

COMPLETE CLEFT ATTACHED TO SKIN AND LATERAL DOWN DIVIDING INTO MEDIAL DIVISION TO THE SEPTUM

DIVISION TO THE FOSSA ANTERIOR TO THE NASAL CONCHA THE UPPER PART

OF THE MEDIAL TUBERCLE AND THE FRENULUM THE INFRAORBITAL NERVES

THE OFF TWO TRUNKS BESIDES SPLAYING OUT TO SUPPLY CHEEK GIVE LARGE

WHICH CROSS THE FACE TO THE SIDE OF THE NOSE AND ARCH INFERIORLY

OVER THE ALA TO REACH THE COLUMELLA WHERE THEY FORM NEURO THE VASCULAR BUNDLES WITH DIVISIONS OF THE FACIAL ARTERY TRAVERSING

COLUMELLAPHILTRUM REGION THE INCISOR TEETH RECEIVE NO NERVE

SUPPLY THIS LACK MAY ACCOUNT FOR THEIR EARLY INSECURITY

MOTOR NERVES

THE BRANCHES OF THE FACIAL NERVE FOLLOW THE DISTRIBUTION OF THE

MUSCLES BUT DO NOT SPREAD QUITE SO FAR AS THEY APPROACH FROM THE OF DO SIDES THEY ARE NOT AFFECTED BY THE CLEFT EXCEPT COURSE THEY THE NOT CROSS THE COMPLETE CLEFT THERE IS NO MUSCLE TO SERVE IN

IN CLEFTS WITH TOTALLY ISOLATED PROLABIUM ANYWAY INCOMPLETE MUSCLE THE INTO THE VARYING AMOUNTS OF COURSING BRIDGES PRO

LABIUM TERMINAL NERVE TWIG MAY SNEAK ACROSS IF THERE IS ENOUGH

MUSCLE TO CARRY AND MERIT IT

VASCULAR PATTERNS IN BILATERAL CLEFTS

SUMMERFIELD IN IN THE BILATERAL CLEFT SPECIMENS STUDIED BY KING

BRANCH THE ALA 1954 THE RIGHT FACIAL ARTERY GAVE DESCENDING TO

AND ANOTHER BRANCH TO THE DORSUM OF THE NOSE BUT TOOK NO PART

MEDIAL TUBERCLE THE LEFT FORMED IN THE SUPPLY TO THE ARTERY BONE HORIZONTAL ARCH WHICH CROSSED THE LOWER PART OF THE NASAL

THE MIDLINE INTO DIVISIONS THAT AND THEN SPLIT AS IT REACHED TWO

OF THE SIDE SIDE THE PASSED DOWN THE DORSUM NOSE BY TO PHILTRUM

DIVISION BRANCH THAT WOUND OVER THE REGION HERE EACH GAVE OF THE LATERAL BODY OF THE PREMAXILLA TO REACH THE SHALLOW ALVEOLUS

INCISORS AND ENTERED THE PULP THE TWO DIVISIONS THEN PASSED AND ENDED THE ALONG THE ATTACHMENT OF THE FRENULUM SUPPLYING THE MEDIAL INCISOR TEETH THEY FINALLY ANASTOMOSED WITH SPHENO

THE ARTERIAL TRUNKS WERE PALATINE ARTERY THE VEINS ACCOMPANYING

PLEXIFORM IN ARRANGEMENT WITH INTERCOMMUNICATIONS

28 WITH AND WAYNE SLAUGHTER PATHOLOGIST JAMES HENRY IN 1960 IN PLASTIC AND RECONSTRUCTIVE COM JACK BERGER SURGE THE VASCULAR OF NORMAL PEOPLE WITH THOSE OF FOUR PARED PATTERNS WITH CLEFTS AND SERIAL SECTIONS HUMAN SPECIMENS MICROSCOPIC FROM 20 CLEFT INFANTS THEY NOTED

LABIAL IN THE COMPLETE BILATERAL CLEFT THE SUPERIOR ARTERY FAILS TO UNITE WITH ITS

FELLOW FROM THE OPPOSITE SIDE AND CONTRIBUTES NOTHING TO THE BLOOD SUPPLY IN ADDITION THE ARCADE MADE THE OF THE PHILTRUM TO THIS UP BY ANASROMOSTS

OF THE POSTERIOR SEPTAL BRANCH WITH THE GREATER PALATINE ARTERY THROUGH THE AND INCISIVE FORAMEN IS ABSENT THE PHILTRUM PREMAXILLA MUST THEREFORE AND DERIVE THEIR BLOOD SUPPLY FROM THE POSTERIOR SEPRAL ARTERY TO LESSER

EXTENT FROM THE LATERAL NASAL AND TERMINAL BRANCHES OF THE ANTERIOR ERHMOID COLUMELLA VESSELS WHICH PASS THROUGH THE

DISSECTION OF CLEFT SPECIMENS INDICATE THAT THERE IS USUALLY ONE WELL

DIFFERENTIATED VESSEL ON EITHER SIDE OF THE PREMAXILLA IN THE REGION WHERE THE

INCISIVE FORAMEN SHOULD HAVE BEEN EACH OF THESE VESSELS PASSES ANTERIORLY

AND INFERIORLY INTO THE PHILTRUM WITHIN THE PHILTRUM THEY CONTINUE AND MIDLINE INFERIORLY MEDIALLY IN AN ARC TO ANASROMOSE ACROSS THE IN THE

INFERIOR PORTION OF THE PHILTRUM

DISSECTION OF THE LATERAL SEGMENTS IN CLEFT SPECIMENS SHOWS THE SUPERIO

LABIAL ARTERY ARISING IN APPTOXIMATELY NORMAL FASHION FROM THE ANRERIOT FACIAL

ARTERY AT THE LEVEL OF THE ANGLE OF THE MOUTH BEING UNABLE TO PASS HORIZON

TALLY THROUGH THE LIP BECAUSE OF THE CLEFT IT PASSES SUPERIORLY AND MEDIALLY TO

POINT APPROXIMATELY AT THE LEVEL OF THE LATERAL INFERIOR ATTACHMENT OF THE

ALAR CARTILAGE HERE IT FORMS AN EFFECTIVE ANASTOMOSIS WITH THE LATERAL NASAL THIS ARTERY CONTINUATION OF THE SUPERIOR LABIAL ARTERY PROBABLY REPRESENTS THE

ASCENDING SCPTAL BRANCH WHICH IN THE NORMAL INDIVIDUAL ANASTOMOSES WITH

THE ANTERIOR EXTENSION OF THE POSTERIOR SEPTAL ARTERY

IN THE AREAS IMMEDIATELY ADJACENT TO THE CLEFT THE NORMAL MATURE VESSEL

PATTERNS ARE NO LONGER PRESENT INSTEAD THERE ARE EMBRYONAL VESSELS HAVING BOTH VENOUS AND ARTERIAL CHARACTERISTICS OF VARYING DEGREES ALTHOUGH THE

VESSEL PATTERN IS UNDIFFERENTIATED THERE IS TENDENCY FOR MOST OF THE VESSELS

TO RUN PATALLEL TO THE CLEFT

THE BILATERAL CLEFT VASCULAR PATTERN HERE PORTRAYED WITH SEVERAL

CORRECTIONS IS DRAWN FROM THE RESEARCH OF SLAUGHTER HENRY AND BERGER

29 DORSAL NASAL

TERMINAL BR OF ANT ETHMOIDAL

NG SEJTAL BR OF

SUPERIOR

IN BILATERAL USING ARTERIOGRAPHY ONE INCOMPLETE

MATURE STILLBORNS FOUND POORER

BLOOD SUPPLY IN THE CLEFT SIDES OF THE PHILTRUM BUT ALWAYS RICH

VASCULAR CENTRAL NETWORK STARTING IN THE SEPTAL AND COLUMELLAR

ARTERIES IN THE LATERAL ELEMENTS THE ARTERIES GENERALLY RAN ALONG THE

EDGES OF THE CLEFT TURNING UPWARD PARALLEL WITH THE COURSE OF THE

MUSCLE BUNDLES IN THE LATERAL SIDE THEY WERE USUALLY STRONGER AND

FORMED DENSER NETWORKS THAN ON THE PHILTRUM SIDE

BILATERAL NASAL DEFORMITY LI

HELD IN THE NORMAL PERSON THE PREMAXILLA IS WITHIN THE MAXILLARY

ARCH SO THAT THE GROWTH THRUST OF THE SEPTUM IS CUSHIONED IN PART

BY THE ANCHORING OF ITS UNION IN THE ARCH THE SEPTAL GROWTH KICK

IS RESPONSIBLE FOR FORWARD GROWTH OF THE MAXILLARY ARCH BUT ITS

FORWARD IS THAT OF THE ITSELF THE PROGRESS NOR AS GREAT AS SEPTUM

POINT OF THE SEPTUM IS CARRYING THE TIP OF THE NOSE ALONG WITH EACH

LATERAL ANGLE OF THE MEDIAL AND CRURA OF THE AAR CARTILAGE AND THE

COLUMELLA THE PROUD ADVANCE OF THESE STRUCTURES IS EVIDENTLY

DEPENDENT UPON THE DISTANCE THE SEPTUM PROJECTS BEYOND THE

30 UNDER THESE CIRCUMSTANCES IT PREMAXILLA MIGHT BE CONJECTURED

THE MOST NASAL IS THAT PROGRESSIVE DEVELOPMENT EXEMPLIFIED IN THE

NOSES SEEN IN BRITISH NARROWHIGHBRIDGED ACTORS OFTEN PLAYING THE ROLE OF BUTLER OR EVEN IN THE MIDDLE EAST NASAL HUMPS AND HIGH THE NASAL ROOTS BY SAME DEDUCTIONS THE NASAL FLATNESS OF THE AFRICAN NEGRO AND THE ORIENTAL COULD BACK REPRESENT STEP IN NASAL IT IS THAT IN THE NINETEENTH PROGRESS INTERESTING CENTURY REDUCTION RHINOPLASTY WAS CONCEIVED AND FOR OVER CENTURY HAS BEEN USED AND MODIFIED TO PRODUCE NOSES THAT ARE NEITHER TOO

HIGH NOR TOO LOW BUT STAND BETWEEN THESE EXTREMES

IN THE BILATERAL COMPLETE CLEFT THE PREMAXILLA THANGS IN UNDER THERE NECK AND NECK WITH THE SEPTUM PREVENTING THE SEPTUM FROM AHEAD THE EFFECT OF THIS GOING LACK OF DISCREPANCY ON THE NOSE IS EQUIVALENT TO WHAT HAPPENS TO TENT THAT NEVER HAS ITS

FRONT CENTER INSERTED IT POLE APPEARS TO HAVE FALLEN EFLAT ON ITS

FACE WHEN IT HAS ACTUALLY NEVER GOTTEN THIF THE GROUND IN THE

FIRST NOT IS PLACE ONLY THE NASAL TIP FLAT BUT THE MEDIAL CRURA OF

THE ALAR ARE LEFT CARTILAGES SEPARATED THEIR ANGLES SPREAD AND THE

COLUMELLA BEING UNSTRETCHED IS ALMOST NONEXISTENT

SPREAD OF THE NASAL BASE

THE CLEFTS THROUGH BOTH NASAL FLOORS AND THE MAXILLARY PLATFORM ALSO HAVE EFFECT ON THE DEVASTATING NASAL BASE AGAIN IT IS LIKE TENT WITHOUT ITS CENTER POLE PRECARIOUSLY PITCHED OVER TWO CHASMS OF DIFFERENT WIDTHS WITH THE CENTRAL PENINSULA SET AT HIGHER BUT GROUND IN THE OF ITS RISE VARYING HEIGHT AND THE DEGREE OF ITS LEAN TO ONE SIDE OR THE OTHER THE LACK OF INTEGRITY OF THE NOSTRIL AND ITS SILL SETS THE ALAR BASES FREE TO FLAP LIKE UNATTACHED TENT SIDES THEN WITH THE CONSTANT OF THE PULL UNOPPOSED LATERAL LIP MUSCULATURE THE FLARING AND EVERSION OF THE ALAR BASES ARE EXAG GERATED AND THE SHAPE THICKNESS AND SET OF THE ALAR WINGS ARE PROVOKINGLY ABNORMAL

ALWAYS AN EYE ON THE NORMAL THE OF THE ANATOMY NORMAL HAS BEEN DISCUSSED IN DETAIL IN VOLUME CHAPTER BUT IT IS ALWAYS PLEASURE TO REVIEW THE

31 OF THE BEAUTY NORMAL AND ESSENTIAL IN ORDER TO USE IT AS GUIDE IN

PLANNING TREATMENT AND GRADING RESULTS WISE OLD OWL IVY WHILE SHAVING ONE MORNING IN 1967 NOTED THE CONFORMATION OF THE PHILTRUM

ONE HAS TO AT ONES ONLY GLANCE OWN UPPER LIP IN THE MIRROR TO ESTABLISH THE

FACT THAT THE 14V MIDLINE VERTICAL GROOVE OR PHILTRUM IS DUE TO AN INTERRUPTION OF TY7 CONTINUITY OR DITECTION OF SOME OF THE ORB ICULARIS OTIS MUSCLE FIBERS IN THIS AND AREA THAT THE ORBICULARIS OTIS IS NOT SIMPLE SPHINCTER LIKE THE ORBICULARIS OCULI SHOWS ROUGH MEASUREMENT THAT WITH THE ADULT UPPER LIP THE TOTAL ARREST THICKNESS OF THE LIP LATERALLY IS ABOUT 11MM WHEREAS IN THE CENTRAL VERTICAL GROOVE IT IS ABOUT MM BECAUSE OF THE ABSENCE OF ABOUT

MM IN THICKNESS OF ORBICULARIS OTIS MUSCLE AT THIS POINT II

NORMAL PARTICULARLY PERTINENT ANATOMICAL ASPECTS THAT HAVE

GONE ASTRAY IN THE BILATERAL CLEFT DEFORMITY AND MUST BE SOUGHT

CORRECTED OR CREATED ARE AS FOLLOWS AN INTACT ALVEOLAR ARCH WITH

TEETH IN OCCLUSION LINED UPPER LABIAL SULCUS INTACT

ORBICULARIS ORIS MUSCLE CONTINUITY WITH ITS FIBERS RUNNING IN HORIZONTAL DIRECTION CENTRAL PHILTRUM DIMPLE SYMMET RICAL PHILTRUM COLUMNS EMBRACING THE DIMPLE AND CURVING TO

WARD THE COLUMELLA TO JOIN EACH OTHER BELOW IT OR AT ITS BASE AND

SELDOM RUNNING INTO THE NASAL FLOOR CUPIDS BOW MIDLINE VERMILION RUBERCLE WHITE ROLL LIGHTED RIDGE THE TOPPING MUCOCUTANEOUS JUNCTION OF THE UPPER LIP AN

SHORT IN VERTICAL UPPER LIP ENOUGH LENGTH AT REST TO EXPOSE THE LOWER THIRD OF THE CENTRAL INCISORS AND WITH SMILING AND LAUGHING OF MORE THESE TEETH UNTIL ALL IS SEEN 10 WIDTH OF THE PHILTRUM LESS THAN ONEQUARTER THE WIDTH OF THE LIP FROM COMMISSURE TO

COMMISSURE NORMAL RELATION OF 11 UPPER LIP IN ANTERIOR EVERSION LOWER TO LIP 12 AN ELEVATED SLENDER NASAL RIP 13

GRACEFUL RELATIVELY ELONGATED COLUMELLA SET AT NATURAL NASOLABIAL OF ANGLE 90 TO 120 DEGREES 14 SYMMETRICAL ALAR RIMS 15 UNFLARED ALAR BASES TURNING IN TO FORM NOSTRIL SILLS ACROSS THE FRONT

OF INTACT NASAL AND FLOORS 16 BILATERAL PATENT AIRWAYS AND ALL OF THESE SHOULD BE IN CONSISTENT WITH THE PROPORTIONS SPECIFIC AGE RACE AND SEX

32 NORMAL MEASUREMENTS OF NOSE AND LIP

MEASURED 100 NORMAL CANADIAN ADULTS FARKAS AND LINDSAY YOUNG AND FOUND THAT COLUMELLA LENGTH RANGED 50 MALES AND 50 FEMALES WITH MEAN OF 123 IN THE MALE AND FROM 15 FROM 16 TO 10 MM OF 122 IN THE FEMALE THEY ALSO FOUND THAT TO MMWITH MEAN THE FROM 18 TO 26 MM THE VERTICAL LENGTH OF UPPER LIP RANGED 16 TO 24MM WITH OF WITH MEAN OF 22 IN THE MALE AND MEAN THESE CORRESPOND WITH THOSE OF HAJNI 19 IN THE FEMALE FINDINGS AND OF ON WESTERN SOYA ON CENTRAL EUROPEANS HAJNIS EUROPEANS

CLIFFORD AND POOL REPORTED IN 1959

OF 100 NORMAL INFANTS AND CHILDREN UNDER THE AGE OF UEARS WERE THE LIPS BASE OF THE THE MEASURED THE VERTICAL HEIGHT WAS TAKEN FROM THE NOSE TO

BOW AT THE WHITE LINE OF THE VERMILION THE PEAK OF THE CUPIDS AVERAGE INFANR 10 AR THE OF MONTHS VERTICAL HEIGHT OF IMONTHOLD WAS MM AGE

THIS DISTANCE WAS 12 MM AT THE AGE OF YEAR THE VERTICAL HEIGHT WAS 13 MM

OF ADULTS WAS MEASURED AND THEIR VERTICAL WAS GROUP 50 AVERAGE HEIGHT CHILD 17 MM THE ADULT LIP THEREFORE IS ONLY MM LONGER THAN THE AVERAGE ADULT OF NORMAL WERE OF MONTHS OF AGE SURPRISINGLY MANY LIPS APPEARANCE

ONLY 13 MM IN VERTICAL HEIGHT

BRAUER AT THE 1973 DUKE SYMPOSIUM SET THE CUPIDS BOW

WIDTH AT ABOUT 45 MM AND THE VERTICAL LIP HEIGHT AT MM OR